Heart lesion, breathing prophet! Shortness of breath without a cause, or a weakened and weak heart

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Basic information] Male, 62 years old

Disease Type] Dilated heart disease, heart failure

Treatment Hospital] Yangjiang People's Hospital (Triple A)

[Treatment plan] Anti-infection, diuretic, inhibition of ventricular remodeling, oxygenation and other symptomatic support treatment.

[Treatment cycle] Hospitalization for 11 days, unwell follow up

Treatment effect] Respiratory distress improved significantly

I. First acquaintance with the patient

One day ago, while I was in the clinic, a 62-year-old male patient accompanied by an elderly manEntered the clinic with a poor mental state on his face, and shortness of breath could be clearly heard. When I asked him about the reason for this visit, the patient told me: about 2 years ago, he started toHave dyspnea after activity without any obvious cause, but he could climb three flights of stairsLater the dyspnea progressively worsened, and his activity endurance progressively decreased. Six months ago, he developed nocturnal dyspnea, which improved when he sat up, and edema in both lower limbs, which was treated with traditional Chinese medicine, but the effect was not good.

He came to our hospital more than 10 days ago and had a coronary angiography, which reported LAD, RCA wall irregularities, TIMI flow grade 3; coronary artery atherosclerosis; cardiac ultrasound showed that the left ventricular wall segmental motion abnormalities; chest X-ray showed that the heart shadow was enlarged, and the symptoms were relieved after giving diuretic, anti-heart failure and inhibiting ventricular remodeling.

One day ago, the patient came to the clinic with dyspnea aggravated by cold and flu. After understanding the patient's condition, the outpatient clinic recommended that the patient be hospitalized.

II. Treatment course

After admission to the hospital, a specialist examination and related tests were performed to assess the patient's condition. The patient was found to have coarse breath sounds on auscultation of both lungs, and small wet rales could be heard at the base of both lungs; the heart border was enlarged to the left, the heart rhythm was uniform, the heart rate was 65 beats/min, the heart sounds were weak, the third heart sound could be heard, and systolic murmurs could be heard in the apical region.

The blood, urine and stool routine and related biochemical tests were completed. The results showed that the white blood cell count was increased and the percentage of neutrophils was higher. The chest X-ray showed an enlarged cardiac shadow and a thickened right hilar shadow.

Based on the medical history, symptoms, signs and relevant auxiliary examinations, a clear diagnosis of dilated cardiomyopathy, chronic heart failure and cardiac function class III was made. Considering the patient's condition, it was decided to provide symptomatic supportive treatment, including anti-infection, diuresis, inhibition of ventricular remodeling, and oxygenation.

His specific treatment was sporcidine sodium anti-infection, long-term low-flow oxygen therapy, infusion of salvia etc. To improve circulation, oral furosemide to reduce swelling and diuresis, and metoprolol to reduce heart rate symptomatic treatment. It was also combined with TCM treatment by giving acupuncture point compresses and ear acupuncture to promote meridian circulation treatment and facilitate recovery.

The patient recovered well because he and his family were cooperative. After about 5 daysOf hospitalization, the patient's dyspnea was significantly reduced; hisMental outlook improved and the treatment effect was affirmed. After 11 days of hospitalization, the patient's symptoms were significantly relieved and he was discharged. The patient was instructed to pay attention to rest, eat a healthy and regular diet, take drugs regularly to improve circulation, inhibit myocardial remodeling and lower heart rate, keep his mood relaxed and follow up on discomfort.

Third, the patient in the treatment of precautions

1. Patients should trust doctors, actively cooperate with treatment, take medication regularly according to medical advice, and communicate with medical staff in a timely manner if there are problems.

2. During hospitalization, patients should get enough sleep, avoid emotional excitement, reasonable nutrition, low salt and low fat diet.

3, disease health education is very important, patients and family members should learn the relevant disease knowledge, the correct understanding of the disease, can play a multiplier effect.

Fourth, the patient's treatment effect

After the standardized, reasonable and joint treatment programThe patient's pulmonary wet rales disappeared and the symptoms of dyspnea were significantly relieved; the indicators of blood routine, inflammatory index and heart failure were not significantly abnormal on rechecking, suggesting that the disease improved; meanwhile, through health education, the patient had a correct understanding of dilated cardiomyopathy-heart failure. The patient's symptoms improved significantly, and he wasOptimistic, no longer frustrated and irritable. With this, the physical condition is getting better and the quality of life is obviously improved.

V. Precautions for patients in daily life

Heart lesion, breathing prophet! Shortness of breath without a cause, or a weakened and weak heart

1, the diet should be light, low salt and low-fat diet, do not eat spicy and irritating food, keep the bowel movement smooth. Regular work and rest, keep a happy mood and avoid emotional excitement.

2, follow medical advice to take medication, appropriate exercise, enhance physical fitness, improve immunity.

3 、 Participate actively in the popularization of medical knowledge, enhance the understanding of various diseases, and maintain communication and exchange with medical personnel.

VI. Doctor's insight

Dilated cardiomyopathy is a cardiomyopathy in which the left ventricle is predominantly enlarged or both the right and left ventricles are enlarged and the contractile function of the heart is significantly impaired. The cause of the disease is not very clear, and may be related to genetics, environment, inflammatory infection and other factors. The onset of dilated cardiomyopathy is relatively insidious, and clinical symptoms may manifest as dyspnea after progressive activity and progressive decrease in activity tolerance, which may manifest as further dyspnea at night or even telangiectatic breathing with further development of the disease.

In the present case, the patient began to have dyspnea after activity without any obvious cause 2 years ago, and then the dyspnea progressively worsened and the activity endurance progressively decreased. Therefore, after admission to the hospital, the first evening specialist examination as well as relevant examinations were performed, and the final diagnosis of dilated cardiomyopathy and heart failure was made based on the results of ECG, physical examination and CT.

Combined with the patient's condition. It was decided to take symptomatic supportive treatment. During the treatment process, it was obvious to feel the change in the patient's mentality, more trust in the doctor, and more confidence in the disease treatment. With further research and discussion of the disease and health education, the patient and his family also became aware of the disease and the role of each drug, and were very cooperative with our treatment plan and more proactive. The mentality has completely overcome the disease. Therefore, it is important to seek medical attention in a timely manner when you are ill, and to face the disease positively and overcome it mentally. Early to improve the quality of life and return to normal life.

Name: Luo Li

Unit:YangjiangCity People's Hospital

Department:Cardiology

Title:Attending physician